Giving Birth in Canada. Providers of Maternity and Infant Care
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1 Giving Birth in Canada Providers of Maternity and Infant Care
2 Contents of this publication may be reproduced in whole or in part provided the intended use is for non-commercial purposes and full acknowledgement is given to the Canadian Institute for Health Information. Canadian Institute for Health Information 377 Dalhousie Street Suite 200 Ottawa, Ontario K1N 9N8 Telephone: (613) Fax: (613) ISBN Canadian Institute for Health Information Cette publication est aussi disponible en français sous le titre : Donner naissance au Canada : Les dispensateurs de soins à la mère et à l enfant, ISBN
3 Giving Birth in Canada Providers of Maternity and Infant Care
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5 Table of Contents About the Canadian Institute for Health Information v Acknowledgements vii About This Report ix Birthing Trends in Canada Pregnancy and Delivery: Who Provides Care? Family Physicians Obstetricians/Gyneacologists Midwives Anaesthesiologists Nurses Shared Care Other Professionals Involved in Supportive Maternity Care Prenatal Educators Doulas Screening and Diagnostic Testing Special Challenges for Care Providers High-Risk Pregnancies Childbirth in Rural and Remote Areas Birthing in Canada s Far North Birthing in Rural Canada Care in the First Weeks of Life Paediatricians Public Health Nurses Getting Care Over the Phone Lactation Consultants Conclusion What We Know What We Don t Know What s Happenning Fast Facts For More Information
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7 About the Canadian Institute for Health Information Since 1994, the Canadian Institute for Health Information (CIHI), a pan-canadian, independent, not-for profit organization, has been working to improve the health of the health system and the health of Canadians by providing reliable and timely health information. The Institute s mandate, as established by Canada s health ministers, is to develop and maintain a common approach for health information in this country. To this end, CIHI provides information to advance Canada s health policies, improve the health of the population, strengthen our health system, and assist leaders in the health sector to make informed decisions. As of April 1, 2004, the following individuals are on CIHI s Board of Directors: Mr. Graham Scott (Chair), Managing Partner, McMillan Binch LLP Mr. Bruce Petrie (Ex-officio), Interim President and CEO, CIHI Dr. Penny Ballem, Deputy Minister, British Columbia Ministry of Health Services Dr. Peter Barrett, University of Saskatchewan Dr. Laurent Boisvert, Director of Clinical-Administrative Affairs, Association des hôpitaux du Québec Ms. Roberta Ellis, Vice President, Workers Compensation Board of British Columbia Mr. Kevin Empey, Vice President, Finance and CFO, University Health Network Dr. Ivan Fellegi, Chief Statistician of Canada, Statistics Canada Mr. Ian Green, Deputy Minister, Health Canada Mr. Phil Hassen, Deputy Minister, Ontario Ministry of Health and Long-Term Care Mr. David Levine (Observer Status), President and Director General, Régie régionale de la santé et des services sociaux de Montréal-Centre Dr. Cameron Mustard, President and Senior Scientist, Institute for Work & Health Dr. Brian Postl, Chief Executive Officer, Winnipeg Regional Health Authority Mr. Rick Roger, Chief Executive Officer, Vancouver Island Health Authority Dr. Tom Ward, Deputy Minister, Nova Scotia Department of Health Ms. Sheila Weatherill, President and CEO, Capital Health Authority, Edmonton v
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9 Acknowledgements The Canadian Institute for Health Information (CIHI) would like to acknowledge and thank the many individuals and organizations that have contributed to the development of the report. Particularly, we would like to express our appreciation to the members of the Expert Group who provided invaluable advice throughout the process. Members included: Dr. Elizabeth Whynot (Chair), President, British Columbia s Women s Hospital & Health Centre Mr. Jack Bingham (Ex-officio), Director, Health Reports and Analysis, CIHI Dr. Beverley Chalmers, International Health Consultant, Centre for Research in Women s Health, Sunnybrook and Women s College Health Science Centre, University of Toronto Dr. Jan Christalaw, British Columbia s Women s Hospital & Health Centre Dr. K. S. Joseph, Associate Professor, Departments of Obstetrics and Gynecology and Pediatrics, Dalhousie University Dr. Terry P. Klassen, Professor and Chair, Department of Pediatrics, University of Alberta Hospital Dr. Michael S. Kramer, Scientific Director, CIHR Institute of Human Development and Child and Youth Health Dr. André B. Lalonde, Executive Vice President, Society of Obstetricians and Gynaecologists of Canada Dr. Carolyn Lane, Family Physician, The Low Risk Maternity Clinic, Calgary, Alberta Dr. Kyong-Soon Lee, Neonatologist, McMaster University Dr. Miriam Levitt, Research Facilitator, University of Ottawa, Faculty of Medicine Dr. Hajnal Molnar-Szakács, Chief, Maternal and Infant Health Section, Health Surveillance and Epidemiology Division, Population and Public Health Branch, Health Canada Ms. Rachel Munday, Primary Health Care Nursing Consultant, Government of the Northwest Territories, Department of Health and Social Services It should be noted that the analyses and conclusions in the report do not necessarily reflect those of the individual members of the Expert Group or their affiliated organizations. The editorial committee for this report included: Kira Leeb, Geneviève Martin, Susan Swanson (The Alder Group), Cheryl Gula, Patricia Finlay, Jennifer Zelmer, and Jack Bingham. Other core members of the team included Nadia Ciampa, Thi Ho, Nicole Howe, Jeanie Lacroix, Vanita Sahni, and Steve Slade. This report could not have been completed without the generous support and assistance of many others who compiled data; undertook research; worked on the print and Web design, translation and distribution; and provided ongoing support to the core team. Special thanks are also extended to CIHI staff and their families for providing the baby pictures used in this report. vii
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11 About This Report This report is the first in a series of four special reports prepared by the Canadian Institute for Health Information (CIHI) on the health of and health care for Canada s mothers and infants. These reports will focus on the following topics: Giving Birth in Canada: Providers of Maternity and Infant Care Trends in birthing and maternity care and a look at the changing scope of practice for maternal and infant care providers. Giving Birth in Canada: Regional Indicators Regional profiles of selected indicators of the health care and health status of Canada s mothers and infants. Giving Birth in Canada: The Costs Expenditures on maternal and infant care. Giving Birth in Canada: A Profile of Canada s Mothers What we know and don t know about the changing demographics of mothers in Canada and about their experiences in the health care system. Each of these special reports presents a fact-based compilation of current research, historical trends, and new data and findings to assist care providers and decision makers in planning health services in maternity and infant care. These reports complement CIHI s ongoing reporting process and the initiatives of partners such as the Canadian Perinatal Surveillance System (see below). 1 FIGURE Where the Data Come From The figure below shows the most recent completed data year for pan-canadian health data holdings at CIHI, Statistics Canada, and the College of Family Physicians of Canada (as of January 2004) used in this report. CIHI data from previous years are also generally available or National Longitudinal Survey of Children and Youth 2001 or National Physician Database Hospital Morbidity Database National Family Physician Workforce Survey* 2002 or Registered Nurses Database Health Personnel Database Southam Medical Database Discharge Abstract Database Collected by CIHI. Collected by Statistics Canada. * College of Family Physicians of Canada. This report includes a Fast Facts section, to provide an expanded range of comparative data across the country. Whenever the icon to the right appears beside the text, it indicates that related data can be found at the back of this report. F F ix
12 Giving Birth in Canada: Providers of Maternity and Infant Care Building on the Canadian Perinatal Health Report 2003 The Canadian Perinatal Surveillance System (CPSS) is part of Health Canada s initiative to strengthen national health surveillance capacity, delivered through the Health Surveillance and Epidemiology Division. The CPSS monitors and reports on perinatal health determinants and outcomes through an ongoing cycle of data collection and acquisition, expert analysis and interpretation, and communication of information for action. Recently, the CPSS released its Canadian Perinatal Health Report 2003, which includes information on 27 perinatal health indicators on determinants and outcomes of maternal, fetal, and infant health. Statistics for each indicator consist mainly of temporal trends at the national level and provincial/territorial comparisons for the most recent year for which data are available. It can be downloaded free of charge from the following link: x
13 Highlights of This Report Most Canadian babies are born in hospital. Obstetricians are performing an increasing proportion of both vaginal and caesarean births. In 2000 they attended 61% of vaginal births and 95% of all caesarean sections up from 56% and 93% in 1996, respectively. The majority of obstetricians (64%) attended between 101 and 300 deliveries in 1999, whereas family physicians attended, on average, 41 births in Most family physicians provide some maternity care, but fewer deliver babies than in the past. In addition, they are now less likely to deliver multiple births or perform caesarean sections. Instead, more family physicians are sharing care with other providers, providing maternity care for up to 32 weeks before transferring care to other family physicians, obstetricians, or midwives for the rest of the pregnancy and delivery. Ontario researchers recently asked new family physicians who do not deliver babies about the reasons behind their decision. They tended to attribute it to concerns about their personal lives, confidence with their obstetrical skills, fee structures, and the perceived threat of malpractice suits. The number of jurisdictions regulating and funding midwifery services is increasing. So is the number of trained midwives, and more expecting mothers are choosing midwives to deliver their babies either in hospital or at home. Childbirth in rural and remote areas presents unique challenges. Rural family physicians are far more likely to provide obstetrical care than their urban counterparts (27% reported delivering babies in 2000, compared with 12% in urban areas). The number of northern community hospitals offering obstetrical care has decreased over the past two decades, but new birthing centres are now available in some communities. There is a relative scarcity of anaesthesiologists and obstetricians practising in rural and remote areas, compared to urban centres. Similarly, there are lower rates of caesarean section births and vaginal deliveries with epidural anaesthesia in rural areas. Twenty years ago, women often stayed in hospital for close to five days with an uncomplicated birth, and even longer if there were complications. Today, healthy mothers and their infants are typically discharged 24 to 48 hours after delivery. Some research indicates that readmission rates of newborns suffering from jaundice have increased following the move to earlier discharge. xi
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15 Birthing Trends in Canada Popularized through Hans Christian Andersen s 19th-century fairy tales, the image of storks delivering babies endures today in stories and cartoons. In reality, however, babies need human help to arrive into this world. 2 FIGURE Some Providers of Maternity and Newborn Care in Canada Many different professions provide care for pregnant women and their children. The graph below shows the number of selected health care providers per 100,000 Canadians in Paediatric Cardiologists* Paediatric General Surgeons* Birth Doulas**** Midwives*** Obstetricians/Gynaecologists* Paediatricians* Maternal/Newborn Nurses** Family Physicians* Number per 100,000 Population Note: Not all family physicians and obstetricians/gynaecologists provide care for expectant mothers and infants. Sources: *Southam Medical Database, CIHI; **Registered Nurses Database, CIHI;***Health Personnel Database, CIHI; ****Doulas of North America Web site ( In 21st-century Canada, that help may come from any of several kinds of care providers, all of whom have been trained to some degree to assist with the common miracles of pregnancy and birth. Much of this care occurs outside of hospitals, although pregnancy and childbirth are the leading causes of hospitalization among Canadian women, accounting for 24% of acute care stays in The continuum of care includes prenatal care and education, screening and diagnostics, home deliveries, postpartum home support, and newborn and infant care during the first weeks of life.
16 Giving Birth in Canada: Providers of Maternity and Infant Care This report focuses on the changing profile of the people who provide care to Canada s mothers and infants, set within the context of overall birth and population trends. These changes are implicitly part of a larger context, and of the current debate about the future care needs of Canadians and the capacity of our health care system. Explicitly, they raise questions about how maternity care is and will continue to be provided across the country. 2
17 3 FIGURE Pregnancy and Delivery: Who Provides Care? For centuries, most births took place in the home, with help from local midwives, friends, or family. Today, patterns of care for mothers and their babies differ around the world and are evolving over time. Internationally, the World Health Organization declared in 2000 that nurses and midwives continue to play a key role in society s efforts to tackle the public health challenges of our time. 2 In England and New Zealand, midwives attend seven in 10 births. 3 Prenatal Care Choices Among Canadian Women According to Statistics Canada s National Longitudinal Survey of Children and Youth, 97% of new mothers had prenatal care. Most saw a physician (88%). However, 3% received their prenatal care from midwives. Provider Doctor Nurse Other Midwife Nobody % Received Prenatal Care The rate in Holland is even higher (90%), where one third of all babies are born in the home. 4 Canada s experience is different. In a survey, the vast majority (88%) of mothers reported receiving prenatal care from physicians. 5 Most babies are born in hospital with a physician as the attending clinical professional. These patterns have been in place for some time, although they are evolving gradually. Note: Other includes carers not elsewhere specified, such as holistic practitioners or friends and relatives with prenatal experience. Mothers that responded nobody did not have prenatal care from a person; however they may have consulted other resources, such as books, television shows, or the Internet. The percentages add up to more than 100% as respondents could have multiple sources of care. Source: National Longitudinal Survey of Children and Youth, Statistics Canada
18 Giving Birth in Canada: Providers of Maternity and Infant Care Results from earlier surveys indicate that women are open to other patterns of birth and postpartum care. In 1994, Statistics Canada asked Canadian women about their willingness to receive care from health professionals other than doctors during their pregnancy and delivery, and postpartum. Using their responses to this survey, Wen and colleagues reported that: 6 31% of women said they would be willing to go to a birthing centre rather than a hospital to have a baby; 21% were receptive to the idea of having a nurse or midwife deliver their baby instead of a doctor; and 85% would accept postpartum care from a nurse or midwife instead of a doctor. This report profiles the health professionals who care for Canada s mothers and their babies today before, during, and after birth. Birth Trends How do birth trends affect those who are providing maternity and infant care? As fewer babies are born, the need for caregivers changes. Similarly, shifts in types of births may imply changing needs for care and mixes of providers. 4 FIGURE Declining Birth Rates By , Canada s birth rate had declined to 10.5 from 14.5 per 1,000 population in , a drop of 28%. Births per 1,000 Population Since 1990, the Canadian birth rate has been steadily declining. According to Statistics Canada, the birth rate was 14.5 per 1,000 population; 11 years later it had fallen to 10.5 per 1,000 population. That translates to 75,737 fewer babies born. The birth rate has dropped in most provinces and territories (except Nunavut), but the magnitude of the decline varies. Note: Time periods are July 1 to June 30 for each year. Source: Statistics Canada. (2003). Annual Demographic Statistics, Ottawa: Statistics Canada 4
19 5 FIGURE Canada s Moms are Getting Older Like multiple births, births by women over 35 are often considered high-risk, because of their increased risk for birth defects and other pregnancy complications. In 1991, 34% of babies in Canada (excluding Ontario) were born to women age 30 and over. By 2000, this had increased to 42%. % of all Births Age 2000 While the overall birth rate has declined, the rate of multiple births has been increasing steadily for at least the last 10 years. However, the percentage increase in multiple births of which most are twins amounts to less than a 1% increase in the birth rate during this time. 8 Because all multiple births are considered to be high-risk given their increased risk for such things as miscarriage, premature birth, gestational diabetes, pre-eclampsia, and other health issues, more frequent monitoring and specialized birthing skills may be required, placing higher demands on health care providers. Pregnancy and Delivery: Who Provides Care? Note: This excludes live births where maternal age is unknown. Source: Health Canada. (2003). Canadian Perinatal Health Report, Ottawa: Health Canada 6 FIGURE Family Physicians Most mothers receive care from family physicians before, during, and/or after childbirth. The 30,258 practising family physicians in Canada in 2002 accounted for just Average Number of Deliveries per Year While fewer family doctors are billing for obstetrical care, the ones who do are attending more deliveries. In 2000, these family physicians attended an average of 41 deliveries, up from 30 in over half (51%) of all physicians in the country. On average, there were 96 family physicians per 100,000 population, but this rate varied greatly from one region to another. F F Average Number of Deliveries per Year Source: Canadian Medical Association Physician Resource Questionnaire Family physicians can be involved in all stages of maternity and infant care from preconception to prenatal to postpartum and beyond. Almost twothirds (64%) said that they were involved in some aspect of maternity care in 2001, up from 53% in However, not all family physicians provide the full range of maternity care. In 2001, Throughout this report references to family physicians includes both physicians practising family medicine and those practising general medicine. The term family physician has been used in recognition of the fact that, in Canada, family physicians and not general practitioners are most likely to be providing maternity and infant care. 5
20 Giving Birth in Canada: Providers of Maternity and Infant Care less than one in five (19%) family physicians providing some services did intrapartum care (attended births). Of the 19% who reported attending births, 85% reported being skilled at vacuum extractions, 44% did low-forceps deliveries, and 4% did mid-forceps and rotation deliveries. While a higher percentage of family doctors than in the mid-1990s report providing maternity care, fewer are attending births. Fee-for-service billing data from provincial health insurance plans also suggest that family physicians share of births attended has fallen. In 2000, they attended 39% of vaginal births, down from 44% in However, those family physicians still providing this service are doing so more often, on average, than before. According to the Canadian Medical Association Physician Resource Questionnaire, family physicians attended an average of about 30 deliveries per year in 1986, compared to 41 in The proportion of family physicians attending deliveries varied across Canada from 8% to 69% in 2001, depending on the province or territory. Family physicians in the western provinces and territories were more likely to attend deliveries than those in central or Atlantic Canada. 9 Family physicians are also performing fewer caesarean sections and attending at fewer multiple births both of which tend to be more complicated. They were the most responsible doctor for 5% of caesarean section births in 2000, down from 7% in In the case of multiple births, the change was greater: just over 6% of these births were attended by family physicians in But by 2000, this had declined to under 3%. 7 FIGURE Canada s Family Doctors in 2001 In 2001, Canada had 29,627 family physicians. According to billing data for 2001, approximately 16% provided delivery services. Of family physicians providing obstetrical care, 37% were female, up from 32% in Nearly half of family physicians (46%) were 45 years of age or older. Only 4% were under the age of 30; 12% were over 60. Fewer Family Physicians Providing Obstetrical Services Just over 31% of family physicians billed for obstetrical services in 1989, compared with fewer than 19% in These data include only family physicians who bill provincial health insurance plans on a fee-for-service basis. They do not include services provided under alternate payment plans. % of Family Physicians Billing for Obstetrical Services Source: National Physician Database, CIHI 6 Excluding births in Manitoba and Quebec.
21 8 FIGURE According to the National Family Physician Workforce Survey, family physicians living outside urban and suburban areas were more likely to provide maternity care particularly attending deliveries than those living in urban areas. Specifically, 27% of family physicians working in small towns or rural areas provided intrapartum care as part of their practice, compared with 12% of those in urban and suburban areas (including inner city physicians). The level of maternity care (e.g. prenatal, intrapartum, postpartum, or newborn care) provided by family physicians also varied by the age and sex of family physicians, as well as their practice setting. For example, a higher percentage of female than male physicians under 40 reported delivering babies, but for those over 40 the reverse was true. Physicians working in group practices were also more likely to deliver babies compared to those working in solo practice (23% compared to 11%). What Maternity and Newborn Care Do Family Physicians Provide? In Canada, most family physicians involved in maternity and newborn care provide shared care. This means that they provide prenatal care up to a certain number of weeks of pregnancy (often between 24 and 32 weeks) and then transfer care to another provider, such as an obstetrician, a midwife, or another family physician who delivers babies. Some family physicians also attend deliveries, but the proportion varies across the country. In a 2001 survey, 66% of family physicians providing some care for pregnant women and/or newborns in the Yukon and Northwest Territories said that they delivered babies, compared to 7% and 12% respectively in Quebec and Ontario. % Family Physicians B.C. Alta. Sask. Man. Ont. Que. N.B. N.S. P.E.I. When and why are family physicians deciding not to deliver babies? Evidence suggests that these decisions are made, at least in part, during residency. 11 An Ontario study tracked family practice residents throughout their training and for two years afterwards. While 52% of residents planned to practise obstetrics initially, by the time they completed the program, this had fallen to 17%. Only 16% were still delivering babies two years later. The authors suggest that various factors were associated with a decision not to deliver babies. These included concerns about personal lives, confidence with obstetrical skills, fee structures, and the perceived threat of malpractice suits. Those who were planning to provide intrapartum care at the end of their residencies, who did not feel it would greatly impact their personal life, and who practised in smaller communities, were significantly more likely to be attending births two years after the end of their residency. 11 N.L. Y.T./N.W.T. Canada Only Postpartum or Newborn Care Shared Care Intrapartum Care (i.e. Delivering Babies, Postpartum Care, and Newborn Care) Note: Data on only postpartum or newborn care were not available for the Yukon Territory and Northwest Territories. Data from Nunavut were not available. Source: 2001 National Family Physician Workforce Survey, part of the JANUS Project, College of Family Physicians of Canada Pregnancy and Delivery: Who Provides Care? 7
22 Giving Birth in Canada: Providers of Maternity and Infant Care F F Obstetricians/Gynaecologists If family physicians are providing less intrapartum care, which health care professionals are filling the gap? The answer, in large part, is obstetricians. In 2002, there were 1,592 obstetricians/gynaecologists practising in Canada, an average of five per 100,000 population. As for family physicians, their numbers vary by region. Among the provinces, Ontario had the highest rate of obstetricians/gynaecologists per 100,000 population (six in 2002), and Newfoundland, Prince Edward Island, New Brunswick, Saskatchewan, and Alberta had the lowest rate, at four. Not all obstetricians/gynaecologists in Canada provide obstetrical care. A 1999 survey by the Society of Obstetricians and Gynaecologists of Canada (SOGC) found that 17% of respondents do not practise obstetrics at all. Of those who practise both obstetrics and gynaecology, only 29% spent more than half their time on obstetrics. 12 Recent billing information supports these findings. Of those obstetricians/gynaecologists who billed provincial fee-for-service health insurance plans in 2001, approximately 18% had not billed for any obstetrical services. 10 According to a new study, several factors are related to participation in obstetrical care: obstetricians/gynaecologists under 35 were more likely to provide such care, while females and those practising in cities with medical schools were less likely. 13 The total number of births attended by obstetricians has been relatively stable since the mid-1990s. With birth rates falling, this means that they are attending a larger share of deliveries 10, including: 61% of vaginal births in Canada s provinces in 2000, up from 56% in % of all caesarean sections in 2000, up from 93% in % of all multiple births in Canada in 2000, up from almost 92% in 1994 Canada s Obstetricians/Gynaecologists in 2001 In 2001, there were 1,590 obstetricians/ gynaecologists in Canada. Of this number, 1,270 (80%) provided some obstetrical care. Of those providing obstetrical care, 36% were female, up from 27% in Just over 60% were 45 years or older; just under 10% were under age 35; and 9% were over age The survey included 668 obstetricians/gynaecologists, 41% of all obstetricians/gynaecologists in Canada.
23 9 FIGURE Results of a 1999 SOGC survey indicated that the majority (64%) of obstetricians attend between 101 and 300 deliveries a year. 12 % of Deliveries Caesarean Section Trends In Canada, a significant percentage of births occur by caesarean section. Canadian Caesarean Section Rates Except for a dip in the early 1990s, Canada s caesarean section rate has increased in the last two decades. It reached an all-time high of 22.5% of in-hospital deliveries in Pregnancy and Delivery: Who Provides Care? Sources: Statistics Canada ( to ); Hospital Morbidity Database, CIHI ( to ) 10 FIGURE Learning Obstetrics and Gynaecology Each year, graduating medical students choose specialties. According to the Canadian Resident Matching Service, the number of positions offered in obstetrics and gynaecology has been greater than the number of positions filled in the past seven years. Data from Quebec is presented separately, as Quebec training facilities do not participate in the Canadian Resident Matching Service. # of Graduates or Positions Graduates Choosing Obstetrics/Gynaecology as First Choice Obstetrics and Gynaecology Residency Positions Offered Obstetrics and Gynaecology Residency Positions Filled Obstetric and Gynaecology Positions in Quebec Looking Ahead In 1999, the SOGC asked its members about their plans for retirement. Thirtyfour percent of obstetricians/gynaecologists said that they were planning to retire in the next five years ( ). According to CIHI, between 1999 and 2002, there were 114 retired obstetricians/gynaecologists and 27 who were semi-retired. If recent enrolment trends continue, about 250 new physicians would enter residency programs in obstetrics/ gynaecology over the same period. Sources: Canada outside of Quebec: Canadian Resident Matching Service, Quebec data: Conférence des recteurs et des principaux des universités du Québec 9
24 Giving Birth in Canada: Providers of Maternity and Infant Care 11 FIGURE Midwives Modern midwives combine knowledge of obstetrics with traditional midwifery practice and provide care for women in all stages of pregnancy, labour, childbirth, and up to six weeks postpartum. Until the early 1990s, only a few countries, including Canada, did not have midwifery legislation. 4 However, these services are now regulated in British Columbia, Alberta, Manitoba, Ontario, and Quebec. Saskatchewan and the Northwest Territories have also passed midwifery acts, Saskatchewan has yet to be proclaimed. Midwives may also work in other jurisdictions, but their practice is not regulated in the same way. Regulated (and to some extent unregulated) midwives help deliver babies both in the home and in hospital, except in Quebec, where they care for women giving birth in free-standing birthing centres. Regulated midwives can also prescribe appropriate drugs and order required tests during pregnancy. Number of Graduates From Canada's Midwifery Programs Midwives can train at five universities in three provinces (Ontario, British Columbia, and Quebec). The following table shows the number of graduates since The program at l Université du Québec à Trois-Rivières started in 2001, and the program at the University of British Columbia began in the fall of They will graduate their first classes in 2004 and 2005 respectively. School * Laurentian University McMaster University Ryerson University L Université du Québec N/A N/A N/A N/A N/A 0 0 à Trois-Rivières University of N/A N/A N/A N/A N/A N/A 0 British Columbia Total * The small number of graduates in this year may be due to a change in the length of the Ontario programs in 1998 from a two-year to a three-year program. Source: Health Personnel Database, CIHI Although regulation of midwifery is increasing, it does not necessarily mean that the care midwives provide is covered by provincial health insurance plans. While Ontario, Quebec, Manitoba, and British Columbia fund midwifery services from the public purse (as will the Northwest Territories), families in Alberta pay about $2,500 per course of care in out-of-pocket expenses. 4 10
25 12 FIGURE Midwifery Across Canada Midwives are primary health care providers for women in all stages of pregnancy, from the prenatal phase to six weeks postpartum. Some provinces and territories have regulated midwifery. This means that midwives practising in these jurisdictions must have formal training and be licensed to practise. Regulation does not necessarily mean that their services are publicly funded. Jurisdictions also differ in the settings in which they allow midwifery to be practised. Home, Province/ Legislation Out-of-Pocket Hospital, Midwifery Territory (Year) Funded Payment or Birth Centre School B.C. Yes (1998) Yes No Home/hospital Yes Alta. Yes (1998) No Yes Home/hospital/ No birth centre Sask. Yes No Yes Home No (act not yet proclaimed) Man. Yes (2000) Yes No Home/hospital No Ont. Yes (1994) Yes No Home/hospital Yes Que. Yes (1999) Yes No Birth centre Yes (soon to be expanded to home and a few hospitals) Pregnancy and Delivery: Who Provides Care? N.B. No No Yes Home No N.S. No No Yes Home No P.E.I. No No Yes Home No N.L. No No No Hospital No (remote areas only) Y.T. No No Yes Home No N.W.T. Yes Yes Yes Home No (act to be (2004) (before 2004) proclaimed in 2004) Nun. Partially Partially No Birth centre No (one pilot project in Rankin Inlet) Source: Adapted from Hawkins M, Knox S. (2003). The Midwifery Option: A Canadian Guide to the Birth Experience. Toronto: HarperCollins Publishers Between 1993 and 2002, the number of regulated midwives practising in Canada grew from 96 to 413, a 330% increase. Some of this increase reflects regulatory changes, such as registration requirements, rather than actual growth in the number of midwives. Nevertheless, with the increase in the actual number of midwives and in the number of provinces who train and regulate them, more expecting mothers are choosing these health care professionals to deliver their babies. Canada s Midwives in 2001 In 2001, there were over 370 midwives in Canada. Three quarters (over 75%) were female. As of 2001, 54% of Ontario s midwives were over the age of 40(other provinces do not routinely collect this information on their midwives). 11
26 Giving Birth in Canada: Providers of Maternity and Infant Care 13 FIGURE Hospital Births Attended by Midwives in Canada The number of publicly funded hospital births attended by midwives is increasing in several provinces. As seen below, Ontario saw nearly a seven-fold increase between and (Similar data are not available for all years for other jurisdictions). Other data from Ontario show that midwives are increasingly likely to provide care in hospital, rather than the home. For example, the Ontario Midwifery Program from the Ontario Ministry of Health and Long-Term Care estimates that 72% of deliveries attended by midwives in 2000 took place in hospital, up from 61% in % of all Hospital Deliveries Source: Discharge Abstract Database, CIHI Ont. Man. Alta. B.C. 12 Providers and Rates of Interventions While several different types of health professionals are trained to help deliver babies, their education, perspectives, and practice patterns may differ. A number of researchers in Canada and elsewhere have studied how the care midwives, family physicians, and obstetricians provide varies. 14 A Quebec study that compared 961 pairs of pregnant women receiving either midwifery care or medical care in the mid-1990s found that, overall, obstetrical technologies were used less often when women were cared for by midwives. 14 For example, tests such as ultrasound, genetic amniocentesis, and glucose screening were undertaken less often when midwives were primarily responsible for a woman s care. Women cared for by midwives were also less likely to be hospitalized prenatally, to undergo a caesarean section, and to give birth to preterm babies. However, the babies born into the hands of midwives were more likely to need assisted ventilation at five minutes of life. Similar results have been found in other countries. According to American researchers who compared patterns of obstetric care provided to low-risk patients by family physicians, obstetricians, and certified nurse-midwives, certified nurse-midwives were less likely to use continuous electronic fetal monitoring and epidural anaesthesia, and had lower caesarean section rates. There was little difference between the practice patterns of obstetricians and family physicians. 15 In the United Kingdom, researchers looked at the experience of 1,299 pregnant women cared for either by midwives or by a combination of midwives, hospital doctors, and family practitioners. Women cared for by midwives were less likely to have their labour induced and to have an episiotomy. Complication rates and perineal tears were similar in both groups. Women cared for by midwives were also significantly more satisfied with the care they received. 16
27 Canada s Anaesthesiologists in 2001 In 2001, there were 2,420 anaesthesiologists in Canada. Of these, 24% were female, up from 22% in The average age was 48 (0% were under 30 years of age, but 17% were 60 or older). Anaesthesiologists In 2002, there were 2,406 anaesthesiologists in Canada, or 8 per 100,000 population. This rate varies by jurisdiction. These specialists provide pain relief during labour and delivery, anaesthesia during caesarean sections, and neonatal resuscitation, among other contributions to the birthing process. According to the Canadian Anesthesiologists Society, 35% of women in labour annually have epidurals requiring the services of an anaesthesiologist. In some cases, family physicians may also be able to do this procedure. The per capita rate of anaesthesiologists is lower in rural and remote areas; so are rates of caesarean sections and vaginal deliveries with epidural anaesthesia. For example, in urban teaching hospitals in eastern and southeastern Ontario, 63% of vaginal births had epidural anaesthesia. That compares with 11% in small community hospitals. 17 In some cases where anaesthesiologists are not available, general practitioners provide some anaesthesiology services. In other cases, expecting women may receive care in hospitals outside the area. (See section on care in rural and remote north for more information.) F F Pregnancy and Delivery: Who Provides Care? F F Nurses In 2002, more than 5% (12,167) of the total 230,957 registered nurses employed in nursing in Canada identified their primary area of responsibility as maternal/newborn care, about the same as in Nurses are involved at every stage of maternity and infant care from providing childbirth education classes to offering pre-birth home care services to women at high-risk and assisting during labour and delivery. After the birth, public health nurses may also provide follow-up care (including lactation consulting) to new mothers and their babies. Canada s Nurses in 2001 In 2001, there were 231,512 registered nurses employed in nursing in Canada. Of these, 95% were female, about the same as in Most were between 30 and 59 years of age (9% were under 30, but 5% were 60 or older). Shared Care Many pregnant women start their care with one primary health care provider, then transfer to another health professional for the remainder of their pregnancy. For example, many family physicians in Canada provide care up to 32 weeks of pregnancy and then transfer care to other family physicians, obstetricians, or midwives. In some jurisdictions, nurse practitioners may do the same. It has been suggested that collaboration among providers of maternity care is a way to address some of the issues relating to access to care, especially in rural and remote areas. 22 Shared care may also be a way to ensure that providers are making the most of their various skill sets. Collaboration among providers is also often required for high-risk pregnancies. For example, midwives are typically required to refer high-risk deliveries to appropriate physicians. Likewise, family physicians may do the same. The National Family Physician 13
28 Giving Birth in Canada: Providers of Maternity and Infant Care Expanding Roles for Nurse Practitioners Wider use of nurse practitioners (NPs) is part of many primary health care renewal visions. NPs are registered nurses who have received additional education, including training to provide certain services formerly performed only by physicians, such as ordering tests, diagnosing illnesses, and prescribing drugs. NPs may bring a unique perspective and expertise to their roles. For example, some assert that, whereas physicians education tends to emphasize diagnosis and treatment of diseases, nurses focus more on the patient (and family) as a whole, both physically and psychosocially. 18 In this way, the role of nurses in primary health care may complement rather than substitute for the roles of other health care providers. Workforce Survey asked family physicians who provide maternal care if they transferred their moderate-risk patients to an obstetrician: 11% of those who attended births indicated they transferred care. More (63%) said that they continued to provide care but consulted an obstetrician. However, collaboration can be challenging, and it may take time to establish. For example, a survey conducted after the introduction of midwives into the British Columbia health care system found that maternal and newborn nurses and midwives generally provided care to women in parallel rather than by collaborating, and that tension existed between the two groups of professionals. 23 NPs work in most parts of the country, but Canadians in rural and remote areas are more likely to receive care from these professionals. For example, in 2002, about 60% of nurses in the Northwest Territories and Nunavut worked in expanded roles in primary health care settings. 19 Although the particular tasks may vary, most parts of Canada (Alberta, Saskatchewan, Manitoba, Ontario, Quebec, New Brunswick, Nova Scotia, Newfoundland and Labrador, and the Northwest Territories/Nunavut) have passed legislation that allows NPs to practise autonomously. 20 For example, NPs in Ontario may provide pregnancy diagnosis, birth options counseling, and prenatal care to 32 weeks. 21 Elsewhere, tasks that fall outside of their traditional scope of nursing practice must be delegated by a physician. 14
29 Prenatal Educators Other Professionals Involved in Supportive Maternity Care Prenatal education classes, which provide information about various aspects of pregnancy, birth, and early parenting, are often offered in hospitals with maternity services or in the community. Prenatal educators come from a variety of backgrounds, including nursing. No universal certification standards for prenatal educators currently exist in Canada, but a few organizations have established their own certification requirements. As well, some community colleges offer certificate-level, continuous study courses in prenatal education. Doulas Doulas provide non-medical emotional support for expecting mothers and their families during birth and postpartum periods, but do not perform clinical tasks. There are two types of doulas: birth doulas and postpartum doulas. As of January 2004, there were about 200 birth doulas in Canada certified by the Doulas of North America. They provide support primarily during labour and birth. Postpartum doulas provide support in the home following delivery. A doula training course usually consists of a two or three-day seminar where skills in relaxation, breathing, positioning, pain control, massage, and other comfort measures are developed. Doulas are not regulated or certified in Canada, although several organizations offer certification in the U.S. and in some European countries. Labour Support and Caesareans Labour support is a term that describes the presence of an empathic person who offers advice, information, comfort measures, and other forms of tangible assistance to a woman to help her cope with the stress of labour and birth. 24 Many different practitioners are trained to offer support during childbirth, including nurses, midwives, and doulas. Does having continuous support during labour reduce the likelihood of a caesarean section? A systematic review of 14 studies involving 5,000 women from 10 countries compared continuous support from a professional or non-professional caregiver (family members and friends) and regular care (some support, but not continuous). The authors concluded that uninterrupted labour support was beneficial: it was associated with significant reductions of caesarean section deliveries, operational vaginal delivery, and use of pain medication. 25
30
31 Did You Know? In 2003, the Canadian Task Force on Preventive Health Care stated that there was fair evidence supporting the benefits of ultrasound screening during the second trimester in periodic health examinations in normal pregnancies. They reported that ultrasound screening has been shown to contribute to increased birth weights, early detection of twins, decreased rates of induction, and increased rates of abortion for fetal abnormalities. Serial ultrasound screening throughout normal pregnancies is not recommended. Screening and Diagnostic Testing Some health professionals are involved in maternity care at specific points in a pregnancy, rather than on a continual basis. For example, most pregnant women undergo a set of routine screening and diagnostic tests, such as ultrasounds and blood tests. If there are suspected complications or if the pregnancy is high-risk, more invasive and more frequent tests may be undertaken. Radiologists, ultrasound and laboratory technicians, and other professionals perform these tests. In some parts of Canada, particularly rural and northern areas, the limited availability of these professional and technical groups may affect the care available to expectant mothers. More information regarding imaging staff and services is available in Medical Imaging in Canada, a CIHI special report (available at
32
33 Special Challenges for Care Providers In popular song, pregnancy and childbirth have been referred to as a common little miracle. When all goes according to plan, women have healthy pregnancies and babies are born without the need for extensive medical intervention. However, there are cases for which special types of care are needed in order to ensure the safety of both mother and infant. Pregnancies are deemed high-risk if there is a higher-than-average chance of complications developing. For example, women with a history of medical conditions such as gestational diabetes, heart disease, or those carrying more than one child, may be considered high-risk. A normal pregnancy may also become high-risk when certain problems, such as signs of preterm labour, are identified. Typically, obstetricians tend to coordinate the care of high-risk women, and additional monitoring tests (e.g. ultrasounds) are often suggested. High-Risk Pregnancies Many hospitals have specialized clinics for women experiencing high-risk pregnancies, but these tend to be located in major urban centres. This is also true for hospitals with specialized intensive care units to care for high-risk infants. In Ontario, for example, of the 16 inhospital neonatal intensive care units, 10 are in major urban centres. Did You Know? About 10% of all pregnancies are considered to be high-risk. High-risk pregnancies are those where either the mother, the baby, or both have a higher-than-average chance of developing complications. The complications could be due to a health problem that the mother had before she became pregnant. Or they could have developed during her pregnancy or during delivery. 7
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